Atypical Presentations of Common Disorders Flashcards
Atypical presentation of illness:
an older adult presents with a disease
state missing some of the traditional core
features of the illness usually seen in
younger patients
Atypical presentations Usually include one of 3 features:
- VAGUE presentation of illness
- ALTERED presentation of illness
- NON-PRESENTATION of illness
Risk Factors for atypical presentations
- Increasing age
- esp. 85 years +
- Multiple medical conditions
- multimorbidity
- Multiple medications
- polypharmacy
- Cognitive or functional impairment
Acute Coronary Syndrome etiology
- atherosclerosis of coronary arteries → plaque
rupture → coronary artery occlusion → ischemia
→ infarction
Acute Coronary Syndrome - atypical presentation
- mild or a complete absence of pain
- can occur in the absence of dyspnea
- new-onset fatigue, dizziness, or confusion
- Shortness of breath is more common than chest pain
- Decreased functional status
Acute Coronary Syndrome diagnosis
- Electrocardiogram (ECG) &/or positive biomarkers with findings of ST-segment
depression - Prominent T-wave inversion
- Elevated troponin levels
- Absence of ST-segment elevation on ECG
Acute Coronary Syndrome - Unique Management Considerations for the Elderly (>75 years old)
- Evaluate for therapeutic interventions in a similar manner as younger patients
- Management decisions should not be based solely on chronologic age but on:
- general health
- functional & cognitive status
- comorbidities
- life expectancy
- patient preferences & goals
- Adjust dosing (weight & est. Cr clearance) of medications
______ preferred
over _____ to reduce cardiovascular
disease events, readmission, &
improve survival rates in the elderly with ACS
Coronary artery bypass graft ; percutaneous coronary intervention
Pneumonia epidemiology
- Top 3 cause of death worldwide
- 2.225 million primary care visits annually in the USA
- 30-day mortality ~10% among patients > 65 years old hospitalized for pneumonia in
USA
Etiology of pneumonia in elderly
- Most common causes of
community-acquired
pneumonia - Respiratory viruses (influenza A & B, rhinovirus, corona virus human metapneumovirus, respiratory syncytial virus, parainfluenza, & adenovirus)
- Streptococcus pneumoniae
- Mycoplasma pneumoniae
- Haemophilus influenzae
- Chlamydia pneumoniae
- Legionella species
- Staphylococcus aureus
- Gram-negative bacilli
Pneumonia - atypical presentation
- May present with:
- weakness
- functional decline
- cognitive impairment or
change in mental status
Pneumonia diagnosis
- Tachypnea with or without shortness of breath → Most reliable sign
- Cough
- Fever
- Sputum production
- Pleuritic chest pain
- Rales or bronchial breath sounds on lung examination
- Infiltrate on chest x-ray or other imaging required for diagnosis
What is a requirement of diagnosis for pneumonia?
Infiltrate on chest x-ray or other imaging required for diagnosis
Pneumonia management
- Comorbidities will likely necessitate
in-patient management - Common first line agents
- amoxicillin/clavulanate cefpodoxime or cefuroxime AND a macrolide OR doxycycline
- levofloxacin (Levaquin®)
- moxifloxacin (Avelox®)
- Early mobilization
Unique Management
Considerations for the Elderly
* Comorbidities
* Polypharmacy
Complications of pneumonia
- Effusion & empyema
- Lung abscess (especially aspiration pneumonia)
- Bacteremia (esp.
Streptococcus pneumoniae pneumonia) - Sepsis
- cardiac complications (new or worsening heart failure, cardiac
arrhythmia, or MI) - ↑ risk of DVT & PE
Hyperthyroidism etiology
- Most common causes
- Graves disease
- toxic thyroid adenoma
- toxic multinodular goiter
Hyperthyroidism - Atypical Clinical
Presentation
- Classic signs
- tremor, irritability, &
nervousness - Often absent in the elderly
- Likely signs in the elderly
- Tachycardia
- Fatigue
- Weight loss
Hyperthyroidism diagnoisis
- Clinical exam
- 20% of patients will NOT have an enlarged gland or palpable nodule
- Ophthalmic signs are frequently absent
- Blood tests
- TSH
- T4 & T3
- Thyroid peroxidase antibodies
- Imaging
- Thyroid scintigraphy
- Radioactive iodine uptake
Hyperthyroidism management
- Treatment of hyperthyroidism
usually depends on underlying
cause - Antithyroid medications,
radioactive iodine, or
thyroidectomy - Beta blockers for symptomatic
thyrotoxicosis - Subclinical hyperthyroidism,
consider treatment in patients at
risk for complications or with
symptoms
Unique Management Considerations
for the Elderly for hyperthyroidism
- Strongly consider treatment if:
- age ≥ 65 years
- postmenopausal women not on
estrogens or bisphosphonates - cardiac risk factors
- heart disease
- osteoporosis
- hyperthyroid symptoms
Treatment for a thyroid storm
Thyroid storm use beta blockers, antithyroid drugs, iodine, corticosteroids, aggressive cooling
measures, volume resuscitation, & ICU monitoring
Hyperthyroidism complications
- Atrial Fibrillation
- Hypokalemic periodic paralysis
- Osteopenia, osteoporosis, &
fractures - Thyroid storm (life threatening)
Acute Abdominal pain etiology
- Esophagitis, PUD, gastritis, cholecystitis,
cholangitis, cholelithiasis, hepatitis, liver
abscess, pancreatitis, abdominal
masses, small bowel obstruction, celiac
disease, diverticulitis, appendicitis, IBD,
IBS, large bowel obstruction, ileus,
constipation, inferior myocardial
infarction, pericarditis, pneumonia, aortic
dissection, AAA, mesenteric ischemia,
nephrolithiasis, UTI, urinary retention,
splenic infarction, PID, leiomyoma,
hernia aka a lot of things
Acute Abdominal pain atypical presentation
- Under recognized
- Most common causes of abdominal pain in the older adult:
- cholecystitis, bowel obstruction, diverticular
disease, complications of cancer, & medication
side effects - Pain is typically NOT focal, but diffuse, mild, possibly absent
- Typically afebrile
- May lack ↑ WBC count
- Mild discomfort & constipation
- Tachypnea & vague respiratory
symptoms
Acute Abdominal pain diagnosis
- High index of suspicion & a wide differential diagnosis required
- Elderly have ↑ mortality rate with acute abdomen
- Workup will be determined by specific suspicions
Unique Management Considerations for
the Elderly with acute abdominal pain
- Often lack caregivers, transportation,
& finances - Fear hospitalization, & losing
independence - Have multiple comorbidities
- Polypharmacy
- Will be admitted more often
Dehydration etiology
- Severe GI loss, limited
oral intake, medications - ie diuretics, renal
disease, diabetes
Dehydration atypical clinical presentation
- Vague or absent signs
- Constipation
- Slight orthostatic hypotension
- May co-occur with:
- Infection
- Tube feedings
- Medications
- Delirium
- Mobility disorders
- Skin turgor is unreliable
in the elderly - Oral dryness may be
unreliable because of
medication side effects - anti-cholinergic
- ↑ mouth breathing
Dehydration diagnosis
- Electrolytes
- BUN
- Cr
- Serum osmolality
- Glucose
- Calcium
- Urine specific gravity
- Urine osmolality
- BUN)/creatine
- ratio > 25
and/or - Na+ concentration
- > 148 mmol/L
Dehydration management
24-hour fluid maintenance
(Crystalloids)
* Adults > 65 years old (50-80 kg)
* 1,500 mL + 30 mL/kg in use
* In febrile patients, +10% of
calculated need per 1 C° > normal
* ~24-hour maintenance
* Na+ 3 mEq/100 mL water
* K + 2 mEq/100 mL water
Dehydration complications
- Hypertonic dehydration may result in
CNS dehydration & brain shrinkage - Hypernatremic encephalopathy,
seizures, coma, respiratory arrest - Isotonic hypovolemia may result in
hypotension or shock - Hypotonic hypovolemia
- Hypovolemia → renal insufficiency,
↓performance in physical & mental
tasks, death
Infectious Disease atypical presentation
- Advancing age → impaired immunity
- Typical symptoms
- Fatigue
- Anorexia
- Urinary or fecal incontinence
- Altered mental status/confusion
- Unexplained and/for recurrent falls
- Loss of functional capacity/ADLs
- Nonspecific malaise without fever
Common infections in the elderly
- UTI
- Pneumonia
- Diverticulitis
- Others
Infectious Disease diagnosis
- WBC may not be ↑ (but there may still be a left shift)
- (+) PPD may be less reliable in the elderly
- May not be febrile
- They tend to have a lower basal temperature
Gout Atypical Clinical Presentation
- Polyarticular arthritis is more
common - May be mistaken for rheumatoid arthritis
- Gouty arthritis & tophi may occur in the presence of osteoarthritic Heberden’s &
Bouchard’s nodes
Gout management
- Crushed ice packs
- Monotherapy (mild-moderate)
- Combo therapy (severe)
- NSAIDS
- Indomethacin
- Systemic corticosteroids
- Colchicine
- Urate-lowering therapy:
- Allopurinol (Aloprim®)
- Febuxostat (Uloric®)
- Elderly will be more sensitive to
medication adverse reactions - Consider hepatic and/or renal
dosing as comorbidities dictate
Pulmonary Embolism etiology
- Virchow’s triad
- Endothelial injury
- Stasis
- Hypercoagulability
- DVT travels to the pulmonary
vasculature & occludes blood
supply to one degree or another
Pulmonary Embolism atypical presentation
- Syncope
- 24% of the elderly v. 3% in young patients
- Cyanosis
- Hypoxia
Pulmonary Embolism diagnosis
- Well’s score
- D-Dimer
- CT pulmonary angiography
Pulmonary Embolism management
- Novel oral anticoagulants
- Low-molecular-weight heparin (Lovenox®)
- warfarin
Pulmonary Embolism complications
- acute cor pulmonale → shock & death
- recurrent pulmonary embolism
- atrial flutter
- atrial fibrillation
- chronic thromboembolic pulmonary hypertension
- postthrombotic syndrome
- Treatment complications
- Intracranial bleeding
- Heparin induced thrombocytopenia
Epilepsy epidemiology
- 60+ years complex partial seizures are the most common type
- 70% of all cases
Epilepsy atypical presentation
- Sensory & Motor symptoms are more common
- Postictal state tend to last longer than in younger populations
- Hours…even days
Epilepsy diagnosis
- History of 2 + seizures
- NOT precipitated by illnesses or other inciting events
- Interictal epileptic activity on electroencephalogram
Epilepsy management
- Avoid precipitating factors of seizures
- sleep deprivation, fever, alcohol
- Review safety concerns
- bathing, cooking, driving, & injury prevention
- Antiepileptic drugs are main treatment
- effective in 60%-70% of patients
Management Considerations for
the Elderly
* Caution using benzodiazepines
in the Elderly
* Use renal & hepatic dosing
where applicable
Epilepsy complications
- Status epilepticus - potentially life-threatening neurologic disorder defined as ≥ 5 minutes of either
- continuous clinical &/or electrographic seizure activity
- recurrent seizure activity without recovery (return to baseline) between seizures
- Depression following diagnosis, especially if seizures are uncontrolled
- Fractures
Epidemiology of parathyroid disease
- Primary hyperparathyroidism
- women > men (2:1)
- 5:1 in patients > 75 years old
- Secondary hyperparathyroidism
- chronic kidney disease in adults
- ~90% once hemodialysis started
- vitamin D deficiency, esp elderly people
Etiology of parathyroid disease
- Single parathyroid adenoma most common
cause (75%-85% of cases)
Atypical Clinical Presentation of parathyroid disease
- No moans, no groans, no bones
- Acute confusion
- With or without volume
depletion
Parathyroid Disease diagnosis
- High parathyroid hormone levels
- Low 1,25-dihyrdroxyvitamin D
- ↓ calcium absorption
- ↓ albumin in the elderly = most common cause of hypocalcemia
Parathyroid Disease management
- Primary → surgical management
- parathyroidectomy
- Secondary → vitamin D
compounds ↓ PTH levels but ↑
risk of hypercalcemia &
hyperphosphatemia in patients
with CKD
Parathyroid Disease complications
- Primary hyperparathyroidism
- Hypercalcemic crisis
- acute hypercalcemic crisis
with nephrogenic diabetes
insipidus & dehydration - profound mental obtundation
or coma is rare but serious
complication of
hypercalcemic crisis
